Perceived quality of antenatal care service by pregnant women in public and private health facilities in Northern Ethiopia

American Journal of Health Research 204; 2(4): 46-5 Published online August 20, 204 (http://www.sciencepublishinggroup.com/j/ajhr) doi: 0.648/j.ajhr.2040204.7 ISSN: 2330-8788 (Print); ISSN: 2330-8796 (Online) Perceived quality of antenatal care service by pregnant women in public and private health facilities in Northern Ethiopia Girmatsion Fesseha, *, Mussie Alemayehu, Belachew Etana 2, Kiday Haileslassie, Ayalnesh Zemene 3 School of Public Health, Reproductive Health and Nutrition team, Mekelle University, Mekelle, Ethiopia 2 School of Public Health, Health service Management Team, Mekelle University, Mekelle, Ethiopia 3 Department of Midwifery, Obstetric and gynaecology team, Mekelle University, Mekelle, Ethiopia Email address: girmaf4@yahoo.com (G. Fisseha), mossalex75@gmail.com (M. Alemayehu), belachewetana@yahoo.com (B. Etana), hkiday@gmail.com (K. Hailasillassie), ayum2@yahoo.com (A. Zemene) To cite this article: Girmatsion Fesseha, Mussie Alemayehu, Belachew Etana, Kiday Haileslassie, Ayalnesh Zemene. Perceived Quality of Antenatal Care Service by Pregnant Women in Public and Private Health Facilities in Northern Ethiopia. American Journal of Health Research. Vol. 2, No. 4, 204, pp. 46-5. doi: 0.648/j.ajhr.2040204.7 Abstract: Background: Quality of Antenatal care is potentially one of the most effective health intervention for preventing maternal morbidity and mortality particularly in places where the general health status of women is poor. Improving quality of health care is one of the strategies in Health sector development program IV (HSDP IV) of Ethiopia. However, there are limited studies on quality of antenatal coverage in Ethiopia including the study area. Thus, the aim of this study was to assess the perceived quality of Antenatal care of pregnant women in public and private health facilities in Tigray, Northern Ethiopia. Methods: Health institution based cross sectional study was conducted from February to May, 203 in Tigray region among 526 pregnant women attending Antenatal care clinic. Participants were selected using multistage sampling technique first health facility were selected using lottery method then pregnant women from each selected facility were selected using systematic sampling method according to the flow pregnant women to the ANC clinics. Data were entered and cleaned using EPI-info version 3.5. and analysis was performed by SPSS version 20. Bivariate and multivariate logistic regression analysis was used to calculate odd ratio with 95% confidence level. Statistical association between the dependent and independent variables was ascertained at p-value less than 0.05. Results: The prevalence of overall perceived quality of ANC was 24.5%. Factors like women aged between 26 and 35 years [AOR=0.58(0.38-0.88)], governmental institution ANC attendance [AOR=0.52(0.33-0.83)], own income [AOR=0.6(0.40-0.92)], one to three ANC attendance [AOR=0.3(0.8-0.54)], testing for HIV [AOR=0.2(0.06-0.24)] causes less likely to perceived that getting high quality ANC service however, waiting time greater than one hour [AOR=3.42(.6-7.28)] is positively associated with mother perception toward getting high quality ANC service. Conclusions: This study revealed that the perceived quality of ANC is very poor. Therefore, urgent action is mandatory to improve the quality ANC service by providing women centered approaches in giving care, in-service training to health care providers on quality practices. Keywords: Perceived Quality of ANC, Pregnant Women, Northern Tigray, Ethiopia. Introduction Antenatal care is the care that a woman receives during pregnancy, which helps to ensure healthy outcomes of women and newborns (). It is also a key entry point for pregnant women to receive a broad range of health promotion and preventive health service (2). Evidences showed that over 70% of women worldwide have at least one antenatal visit with a skilled provider during pregnancy (3). In the industrialized countries coverage is extremely high, with 98% of women having at least one visit (3). But in Sub-Saharan Africa, the coverage was lower than other regions with 68% of women reports at least one antenatal visit (3) in addition to this, the region has the highest

47 Girmatsion Fesseha et al.: Perceived Quality of Antenatal Care Service by Pregnant Women in Public and Private Health Facilities in Northern Ethiopia maternal mortality rate, reaching levels of 686 per 00,000 live births (4). Almost all maternal deaths (99%) occurring in developing countries are due to complications arising during Antenatal, Intera-partum and immediate postnatal period (5). Of the deaths more than half of them occur in sub-saharan Africa and one third occur in South Asia. Most causes of these deaths are easily preventable through antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth (5). However, in many African countries the coverage ANC is increasing. But the coverage alone does not provide information on quality of care, and poor quality in ANC clinics, correlated with poor service utilization, is common in Africa. This is often related to an insufficient number of skilled providers (particularly in rural and remote areas), lack of standards of care and protocols, few supplies and drugs, and poor attitudes of health providers (6). In Ethiopia, the 20 DHS results show that only 34% of women received antenatal care from a trained health professional at least once for their last birth. And in Tigray region, 50% of the women received the care from skilled providers (7). Despite the fact that maternal health care quality is essential for further improvement of maternal and child health, little is known about the current perceived quality of the service and factors influencing in Ethiopia including in study area. Therefore, the purpose of this study is to understand the current status of perceived quality of antenatal care services provision among pregnant women attending ANC in Tigray region, northern Ethiopia. The results will also help the policy makers on understanding of the quality of antenatal care and it may serve as a evidence for intervention aimed at improving the quality of maternal health care provided at health settings in the country. 2. Methods 2.. Study Population and Area A study was conducted in Tigray Region, northern Ethiopia in public and private from February to May, 203 among pregnant mothers attending ANC follow-up service. In the region, there were about 985,654 households with an average of 4.4 persons to a household. The region has about 6 governmental, 2 private hospitals and 2 health centers. (8). 2.2. Study Design and Sample An institution based cross-sectional study was conducted among 526 pregnant women. The sample size was calculated using a single population proportion formula by taking previous prevalence from Sudan; which is 22% of pregnant women s satisfied about the service given at ANC (9) with 95 % confidence interval and a precision of +5%, and after considering the designs effect of two we got the final sample of 526 pregnant women. Study participants were selected by multi-stage sampling technique first from the total 8 hospitals and 2 health centers in the region; five hospitals (two private and three public) and seven health centers were selected by the lottery method after stratified to public and private as well as health center and hospital. Then, sampling frame was developed from every selected health facilities using average last four months client flow statistics at each antenatal clinic. After that, the sample was allocated to the health facilities by proportional allocation to size, the more the facility with many attendance the higher number of pregnant mother were included in the study. Finally pregnant women at each antenatal clinic were selected using systematic random sampling. 2.3. Measurements Data was collected using exit interview in the selected health facilities when pregnant women come for regular follow up. A pretested structured questionnaire was adapted from the WHO (0). The instrument was first prepared in English and then translated to the local language, Tigrigna, to make easily understandable and reduce language barriers between the data collectors and study subjects. It contained information on socio-demographic characteristics of study participants and other perception questions. To measure the perceived quality of the service provision, 25 items question was used. Which were focused on providing information on danger sign (8 items), information on birth planning (6 items), information on nutrition, whether getting vaccination, whether lab test of blood and urine, whether weight, height and blood pressure measures, and clarity on appointment time ( items). Respondents were interviewed at exit after they got their service by trained data collector. The overall data collection activity was controlled by the principal investigator of the study. All completed questionnaire was examined every day after data collection for completeness and consistency. 2.4. Data Processing and Analysis The collected data were coded, entered and cleaned by EPI Info version 3.5. and was analyzed by SPSS version 20. The data were summarized by descriptive statistics like frequency distribution and mean. Perception about quality of ANC service was considered as dependent variable. To measure the perceived quality of care, the mean score of the questions which were intended to measure the perceived quality of ANC service were taken into consideration. A client who had scores above the mean was labeled as high perceived quality care; otherwise client was categorized as low perceived quality care. Bivariate and multivariate analyses were done using logistic regression analysis. Odds Ratio with their 95% Confidence Interval was determined to see the association between the dependent and independent variables. P < 0.05 was considered as statistically significant association. The

American Journal of Health Research 204; 2(4): 46-5 48 variables were included to multivariate analysis, if they show stastical significant analysis during bi-variate analysis. 2.5. Ethical Considerations The study protocol was reviewed and approved by health research ethics review committee of the College of Health Sciences at Mekelle University. Official letter of cooperation was obtained from Tigray regional Health Bureau and was distributed to selected districts administrative offices, hospitals and Health centers. Moreover, an informed oral consent was obtained from each study subject. Confidentiality and privacy was maintained during data collection. Besides this, no personal identifier was taken and each questionnaire was coded. 3. Results 3.. Socio-Demographic Characteristics of Participants In this study, five hundred nineteen pregnant mothers were interviewed with a 98.7% response rate. The majority, 347 (66.8%) of study participants were from urban while 72 (33.2%) pregnant mothers were from rural residence. In average the study participants was 28. (±6.2 SD) years. Majority of study participants, 426 (82.%) were Orthodox Christian, 490 (94.4%) were from the Tigray ethnic group and 22(42.6%) of them were housewives. One hundred forty two (27.4%) of the study participants had no formal schooling, while 52 (29.3%) had completed -8 grades. Similarly, 7 (22.5%) of the study participant s husbands had no formal schooling (Table ). Table. Socio-demographic characteristics study participants (n=59), Tigray, Northern Ethiopia Socio-demographic variables Frequency % Maternal age groups 7-25 90 36.6 26-35 273 52.6 36-50 56 0.8 Maternal educational status Have no formal education 42 27.4 Completed -8 grades 52 29.3 Completed high school (9-2) 5 29 College/University level 74 4.3 Paternal education status Have no formal education 7 22.5 Completed -8 grades 35 26 Completed high school (9-2) 37 26.4 College/University level 30 25. Maternal religion Orthodox 426 82. Muslim 75 4.5 Catholic 0.9 Protestant 8.5 Residence Rural 72 33. Urban 347 66.9 Ethnicity Socio-demographic variables Frequency % Tigray 490 94.4 Amhara 2 4 Oromo 5 Others 3 0.6 Maternal occupation status Housewives 22 42.6 Civil servants 03 9.8 Traders 93 7.9 Farmers 90 7.3 Daily laborers 2 2.3 Paternal occupation status Traders 52 29.3 Civil servants 5 29 Farmers 37 26.4 Daily laborers 56 0.8 Students 23 4.5 Have own income Yes 96 37.8 No 323 62.2 3.2. Reproductive and Obstetric History Majority of the women get married from 8 to 25 years of age with mean at first marriage of 9.9 (±3.4) years. Beside this, three hundred forty five (66.5%) of the study participants had -3 parities and 9 (3.7%) had greater than or equal to 7 parities with a mean parity of 2.9 (±.8 SD) including the current pregnancy. Moreover, three hundred forty two (65.9%) of the study participants ever gave birth. Of those who ever gave birth, majority s age at first delivery, 284 (83%) was in the age range of 8-25 years. Similarly, majority of the study participants, 275 (95.5%) had to 3 number of under five children with a mean family size of 3.7 (±.9 SD) people per household (Table 2). Table 2. Reproductive and Obstetric history of pregnant women attending health facility in Tigray, northern Ethiopia Reproductive and Obstetric Variables Frequency % Age at first marriage < 8 years 28 24.7 8-25 years 355 68.4 26 years 36 6.9 Number of parity -3 345 66.5 4-6 55 29.8 7 9 3.7 Ever gave birth Yes 342 65.9 No 77 34. Age at first delivery (n=342) <8 years 3 9. 8-25 years 284 83 26-30 years 27 7.9 Number of children born (n=342) -3 228 66.7 4-6 05 30.7 7 9 2.6 Number of under 5 children (n=288)

49 Girmatsion Fesseha et al.: Perceived Quality of Antenatal Care Service by Pregnant Women in Public and Private Health Facilities in Northern Ethiopia Reproductive and Obstetric Variables Frequency % -3 275 95.5 4 3 4.5 Total family size 3 295 56.8 4-6 69 32.6 7 55 0.6 Faced abortion Yes 7 3.7 No 448 86.3 Faced child death Yes 54 0.4 No 465 89.6 3.3. Perceived Quality of ANC Service The prevalence of overall perceived ANC quality was about 24.5% among pregnant women who visited both private and public Antenatal Care Clinics. Majority of the study participants (89.8%) felt they had enough time to discuss health issues with the service providers and 4.6% felt the time was inadequate for proper client provider interactions. Perception of poor quality ANC service is higher (42.6%) among women who had visited public institution compared to private (0.2%). About 66% of pregnant women involved in decision making about the care given (Table 3). Table 3. Perception of pregnant women about quality care during ANC visits in health facilities in Tigray, Northern Ethiopia Perception Variables no % Poor Perceived quality care Public institutions 22 42.6 Private institutions 53 0.2 Waiting time in minutes 0-30 362 69.7 40-60 6 22.4 >60 4 7.9 Mother Got enough time with health provider during ANC visit Yes 466 89.8 No 29 5.6 Involved in decision making Full 343 66.% Moderately 44 27.7% Not involved at all 32 6.2% 3.4. Factors Associated with Perceived Quality ANC Service Multiple logistic regression analysis showed that women age, place of ANC attendance, income, number of ANC visit, testing for HIV and waiting time were independently associated with the perceived quality of ANC services that the study participants were receiving at the respective health facilities (Table 4). Table 4. Bivariate and multiple logistic regression analysis forfactors related to perceived quality of ANC service among pregnant women attended ANC in public and private health facilities, Tigray region, Northern Ethiopia Variables Place of ANC attend Government Private Age of mothers 7-25 years 26-35 years > 36 years Residence of women Urban Rural Own income Yes No Faced abortion Yes No Number of ANC -3 > 4 Waiting time (overall) 0-30 minutes 40-60 minutes > 60 minutes Involved in decision Very Medium Not Tested for HIV Yes No Perceived Quality of ANC Higher n (%) Lower n (%) 79 (34.5) 66 (2.7) 99 (9.) 6 (22.4) 30 (5.8) 52 (29.3) 93 (7.9) 76 (4.6) 69 (32.6) 42 (8.) 203 (39.) 87 (36.0) 58 (.2) 65 (3.8) 52 (0.0) 28 (5.4) 36 (26.2) 85 (6.4) 24 (4.6) 88 (36.2) 56 (0.8) 22(42.6) 53 (0.2) 9 (7.5) 57 (30.2) 26 (5.0) 95 (37.6) 79 (5.2) 20 (23.) 54 (29.7) 29 (5.6) 245 (47.2) 248 (47.8) 26 (5.0) 97 (38) 64 (2.3) 3 (2.5) 207 (39.9) 59 (.4) 8 (.5) 263 (50.7) (2.) Crude OR (CI) 0.65 (0.43-0.98) * 0.68 (0.47-0.98) *.5 (.05-2.8) * 0.58 (0.40-0.83) *.75 (.05-2.9) * 0.34 (0.2-0.56) * 2.57 (.29-5.3) * 0.22 (0.09-0.50) * 0.4 (0.07-0.28) * Adjusted OR (CI) 0.52 (0.33-0.83)* 0.58 (0.38-0.88)* 0.6 (0.40-0.92)* 0.3 (0.8-0.54)* 3.42 (.6-7.28)* 0.3 (0.3-0.79)* 0.2 (0.06-0.24)* *Statistically significant at 95% confidence interval

American Journal of Health Research 204; 2(4): 46-5 50 4. Discussion The overall prevalence of the perceived quality ANC was 24.5% among pregnant women. This is much lower than the finding of the study conducted in Khartoum in which the prevalence of overall perceived quality care among pregnant was 38% (9). The difference may be due to poor infrastructure and skill of the provider in our set up. In this study, we found that 69.7% of the study participants had a waiting time ranging from 0-30 with a mean waiting time of 3.8 (±23 SD) minutes for getting the required services. This is similar the reported waiting time from in Mushin, Lagos, which is about 69.03 ± 2.64 minutes (). This difference may be due to less prevision of technical service by health professional in our setup. In addition, there is lower ANC attendance in our facilities taken from the national survey. In our study, majority of the study participants (89.8%) felt they had enough time to discuss health issues with the service providers and 4.6% felt the time was inadequate for proper client provider interactions. This is lower than the finding of a study conducted in Lagos, Nigeria where most clients (94.6%) felt they had enough time to discuss health issues with the service providers and 4.0% felt the time was inadequate for proper client provider interactions (2). More than half of the respondents (66.%) felt they were properly involved in the decision making process of their care. This finding is much lower than the study conducted in Lagos, Nigeria where most respondents (87.0%) felt they were properly involved in the decision making process concerning their care (2). In this study, perception of poor quality ANC service is higher (42.5%) among pregnant women who serve at Governmental clinics compared to private facilities (0.2%) which is similar compared with other study in Nigeria and Ethiopia (3, 4). The possible reason may be due to small sample size. In multivariate analysis; place of ANC attendance has also a significant association with the perceived quality of ANC service, i.e. those who were following their ANC at government institutions were 48% less likely to perceive high quality ANC service as compared to those who were attending at private institutions. The probable reasons could be high client flow, busy health care providers and less paid health care workers in governmental facilities as compared to the private ones. Women whose age is between 26-35 years were 42% less likely to get quality ANC service as compared to those whose age is between 7-25 years. This is because the women whose age is between 26-35 years are more aware and have a lot of expectations with regard to their ANC service. On the other hand, women who had a waiting time of greater than 60 minutes were 3.42 times more likely to perceived quality ANC service as compared to those whose waiting time was 0-30 minutes [AOR=3.42 (.6, 7.28)]. This is because those who stay longer were getting more time to be investigated and had more time to discuss even among themselves. As limitation, this study was assessed only by the report of pregnant mothers; no observation was done during the care so under reporting or over reporting can be possible result. In addition, recall bias of mother could be also affecting the finings. Therefore, any interpretation of this finding within these variables shall take into account the degree of precision. However, as strength, this study uses measurement from WHO which is enabled to make the comparison of findings with other national and international literatures to be valid. In addition, before conducting this study, pretest and training for data collectors and supervisors was done. 5. Conclusion The prevalence of overall perceived quality was low among pregnant women who visited both private and public Antenatal Care Clinic. Women attend at private clinics have high perception about the quality given during ANC visits than those attend in public facilities. In adequate time to discuss health issues with the service providers and lower involvement in the decision making process concerning their care is other problem. Women age, place of ANC attendance, income, number of ANC attendance, testing for HIV and waiting time were independently associated with the perceived quality of ANC services that the study participants were receiving at the respective health facilities. As recommendation, giving emphasis in counseling mother by training providers; improve the waiting time; increase the involvement of mothers in the decision making process and giving much time to mother during each visits to discuss their concern freely; addressing the low level of awareness and expectations of the younger women regarding ANC services, and experience sharing between private and public facilities are important interventions. Acknowledgement We would like to acknowledge Mekelle University, College of Health science for financial support. We also thanks Tigray Regional health bureau, managers of all health facilities for facilitating good conditions to carry out the study and the study participants who share their priceless time, supervisors, and the data collectors for their full commitment and technical support. Competing Interests The authors declare that they have no competing interests.

5 Girmatsion Fesseha et al.: Perceived Quality of Antenatal Care Service by Pregnant Women in Public and Private Health Facilities in Northern Ethiopia Authors Contributions GF : MA : BE 2 : KH : AZ 3 : has taken a principal role in the conception of ideas, developing methodologies and writing the article. And they were involved in data collection, analysis, interpretation of the data and preparing in this manuscript. These authors contributed equally to this work and accepted the final manuscript. References [] Abou-Zahr, Carla L, Wardlaw, Tessa M. Antenatal care in developing countries: promises, achievements and missed opportunities: an analysis of trends, levels and differentials, 990-200. Genva: WHO, UNICEF 2003. [2] USAID. Focused Antenatal care: Providing integrated, individualized care during pregnancy 2007. [3] UNICEF, WHO. Data from Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS) and other national surveys, late 990s to 200. 04 countries. Averages weighted by number of births 2002. [4] Yared M, Mekonnen A. Utilization of Maternal Health Care Services in Ethiopia. Calverton, Maryland, USA: ORC Macro 2002. [5] World Health Organization Maternal mortality fact sheet No. 348. 200 [cited 20 December 3]; Available from: http://www.who.int/mediacentre/factsheets/fs348/en/index.h tml. [6] Ornella L, Seipati M-A, Patricia G, Stephen M. Antenatal Care. Opportunity for African s newborn, 2003. [7] Centeral Statistics Agency, ICF Macro Calverton. Ethiopia Demographic and Health Survey 20. Addis Ababa: CSA 20. [8] Federal Democratic Republic of Ethiopia Population census commission. Summary and Statistical Report of the 2007 Addis Ababa 2007. [9] Zeidan Z, Idris A, Bhairy N. Satisfaction among pregnant women toward Antenatal care in public and private in Khartoum. Khartoum Medical Journal 20; 4(2):590-5. [0] Villar J, Bergsjo P. WHO Antenatal Care Randomized trial: Manual for the Implementation of the New Model. Genva: WHO; 2003. [] Sholeye OO, Abosede OA, and Jeminusi OA. Three Decades after Alma-Ata: Are Women Satisfied with Antenatal Care Services at Primary Health Centres in Mushin, Lagos? Journal of Medicine and Medical Science Research. ISSN 2277-0879, 203; 2(3): 24-29. [2] O.O. Sholeye, O.A. Abosede and O.A. Jeminusi. Client Perception of Antenatal Care Services at Primary Health Centers in an Urban Area of Lagos, Nigeria. World Journal of Medical Sciences, 203; 8 (4): 359-364. [3] Tadese Ejigu, Mirkuzie Woldie and Yibeltal Kifle. Quality of antenatal care services at public health facilities of Bahir- Dar special zone, Northwest Ethiopia. BMC Health Services Research 203, 3:443. [4] I.L. Nwaeze, O.O. Enabor, T.A.O. Oluwasola, C.O. Aimakhu. Perception and Satisfaction with Quality of Antenatal Care Services among Pregnant Women at the University College Hospital, Ibadan, Nigeria. Ann Ibd. Pg. Med 203; (): 22-28.